HEALTH EDUCATION RESEARCH
Vol.24 no.3 2009
Pages 407–420
Advance Access publication 11 July 2008
‘Ready. Set. ACTION!’ A theater-based obesity
prevention program for children: a feasibility study
Dianne Neumark-Sztainer1*, Jess Haines2, Ramona Robinson-O’Brien1, Peter
J. Hannan1, Michael Robins3, Bonnie Morris3 and Christine A. Petrich1
Abstract
This study examined the feasibility of implementing an innovative theater-based afterschool program, ‘Ready. Set. ACTION!’, to
reach ethnically diverse and low-income children and their parents with obesity prevention
messages. The study population included 96
children and 61 parents. Children were in
fourth to sixth grade and 41% were overweight
at baseline. Program impact was evaluated with
a pre/post-randomized controlled study design,
but a major focus was placed on the process
evaluation conducted in the intervention
schools. Intervention children and parents
reported high program satisfaction and that
they had made changes or intended to make
positive changes in their behaviors due to program participation. However, few meaningful
differences between the intervention and control conditions were found at follow-up. Thus,
the combined process and impact evaluation
results suggest that the intervention was effective in leading to increased awareness of the
need for behavioral change, but was not powerful enough on its own to lead to behavioral
change. From this feasibility study, we con1
Division of Epidemiology and Community Health, School of
Public Health, University of Minnesota, 1300 South Second
Street, Suite 300, Minneapolis, MN 55454, USA,
2
Department of Ambulatory Care and Prevention, Harvard
Medical School/Harvard Pilgrim Health Care, Boston, MA
02215, USA and 3Illusion Theater, Minneapolis, MN 55403,
USA
*Correspondence to: D. Neumark-Sztainer. E-mail:
[email protected]
cluded that Ready. Set. ACTION! offers promise as a creative intervention strategy. The next
research step may be to incorporate theaterbased programs into more comprehensive
school-based interventions, with both educational and environmental components, and
evaluate program impact.
Introduction
The high prevalence of obesity among children is of
concern given its physical, behavioral and psychosocial consequences [1–3]. Of particular public health
concern, are the disparities in obesity across ethnicity and social class, with high prevalences among
ethnically diverse and low-income populations
[4–6]. Given the challenges inherent in changing
behaviors of relevance to obesity, the complexity
of providing messages that are appropriate for diverse cultural groups, and the importance of ensuring that messages do not harm a child’s developing
body image and self-esteem, creative intervention
strategies are needed to reach children at greatest
risk for obesity. Furthermore, given the importance
of families in helping children engage in healthy
behaviors and the difficulties often encountered in
involving parents in school-based health promotion
initiatives [7], it is imperative that novel strategies to
reach parents are developed and evaluated.
One promising and creative strategy for reaching
children and their families with health-related messages is through the use of theater [8, 9]. The performance of a play offers children a peer leadership
opportunity in which they get to teach others,
Ó The Author 2008. Published by Oxford University Press. All rights reserved.
For permissions, please email: [email protected]
doi:10.1093/her/cyn036
D. Neumark-Sztainer et al.
possibly increasing their sense of self-empowerment
and ownership of the messages. Additionally, theater, or more specifically a play production in which
children are the actors, offers a unique tool to bring
behavioral messages into the home by getting
parents to pay attention to those messages. A needs
assessment done by our team suggested that lowincome parents may be more likely to attend an
event in which their children are participants (e.g.
in a play) than an educational event, even if it
involves fun activities (e.g. eating and joint parent–
child classes) [10].
While most theater-based programs have focused on influencing the youth participants in the
program (versus attempting to reach parents) [e.g.
11–13], theater has been explored as an educational
and behavior change strategy for children and their
parents on health-related issues, such as seat-belt
safety [9] and substance use [8]. Previously, we
utilized theater to reach children and their parents
in attempt to reduce weight-related teasing among
children within a more comprehensive schoolbased program and found a decrease in reported
weight teasing among the children [14]. While decreasing weight teasing may have implications for
obesity prevention [15], interventions primarily
aimed at obesity prevention probably need to address a broader scope of risk factors. We are
unaware of any evaluations of theater interventions
that target children and their parents with obesity
prevention messages.
‘Ready. Set. ACTION!’ is an after-school theater
program designed to reach ethnically diverse and
low-income elementary school children and their
parents with messages of relevance to obesity prevention. Our primary aim was to develop and test
the feasibility of implementing Ready. Set.
ACTION!, developed in partnership between
researchers at the University of Minnesota and
artists/educators from Illusion Theater, a Minneapolis-based theater company with experience in educational theater. A secondary study aim was to
examine if participation in this program resulted
in changes in the children’s weight-related behaviors and their home environments that might facilitate the adoption of healthier eating and physical
408
activity behaviors of relevance to weight management. This paper describes the intervention, evaluation, key findings and implications for future
directions.
Methods
Study design and population
The study was conducted in four urban schools in
St Paul, MN, USA, in which ;90% of the students
qualified for free or reduced price lunch [16]. Baseline evaluation was done in the fall 2006 and
follow-up evaluation was done in the spring 2007.
The intervention was implemented in two of the
schools and program feasibility was assessed
among participating children and their parents at
these two schools. In addition, other students at
the intervention schools who saw the play completed a brief viewer survey. Program impact was
evaluated using a pre/post-group-randomized controlled trial with two conditions, intervention and
control, with two schools in each condition. The
intervention condition received the Ready. Set. ACTION! theater-based educational program. The
control condition also participated in a theaterbased intervention, which involved performing
a play focused on environmental health issues using
a prepared script. This study design allowed for the
similar recruitment of children across conditions, as
all children were recruited into an after-school theater health-related intervention. The use of a theater-based control condition also allowed for the
assessment of program impact above and beyond
the experience of participating in a play. Although
the main purpose of the study was to examine program feasibility, we were interested in carrying out
a full evaluation with a study design and assessment
tools that could be used in a future larger scale
study. Ethical approval for the study was received
from the Institutional Review Board of the University of Minnesota and the Saint Paul Schools
Research Committee.
All children in fourth to sixth grades at the intervention and control schools were eligible to participate and were selected on a first come, first
Theater-based obesity prevention
served basis. The baseline study population included 108 children and 73 parents. The followup study population included 96 children (overall
response rate: 89%; intervention: 91%, n = 51;
control: 87%, n = 45) and 61 parents (overall response rate: 84%; intervention: 81%, n = 30; control 86%, n = 31). Approximately 75% of the
surveys were completed by mothers; other primary
caregivers who participated were fathers, stepmothers, grandmothers, aunts and uncles. Primary
reasons for child attrition included moving schools
and/or a change in contact information and primary
reasons for parent non-response or attrition included inability to contact parent or language barriers. Table I shows the baseline characteristics for
all children and separately for children who
responded at follow-up. No response bias was
found for any of these characteristics utilizing
t-tests and chi-square tests as appropriate.
Description of intervention
Social Cognitive Theory (SCT) guided the development of Ready. Set. ACTION! [17, 18]. As
described below and outlined in Fig. 1, the intervention included three components: (i) theater sessions, (ii) booster sessions and (iii) family outreach.
Each of these components addressed constructs
from the domains of child behaviors, personal factors and the home environment.
Theater sessions
Fourteen 2-hour after-school theater sessions were
conducted. Each session included (i) a ‘check-in’ in
which children were given an opportunity to share
any behavioral changes they had made over the past
week such as eating more fruits and vegetables and
talk about how take-home packages were received
by families; (ii) easy-to-prepare healthy snacks; (iii)
a movement component with activities that are fun,
easy and require minimal resources (e.g. dancing or
walking) and (iv) theatrical ACTivities. For the initial sessions, the ACTivities component included
exercises to introduce the children to theater techniques and to build trust and co-operation. In later
sessions, the ACTivities focused on enhancing
knowledge and skills related to physical activity
and healthy eating, as well as promoting a positive
body image, through interactive activities. During
these activities, the children were asked to share
their personal experiences related to being active
and eating healthfully. It was from these explorations that the content of the script for the Ready.
Set. ACTION! play developed. Some examples of
how intervention messages were transformed into
play scenes include the following: (i) the message
of reducing soda pop became a song/dance called
‘Stop the Pop’, (ii) adopting healthier eating and
physical activity patterns became a coach’s pep talk
to his team, (iii) limiting television viewing developed into a humorous horror spoof in which too
much time in front of the television turned children
into zombies and (iv) promoting self-esteem and
body image led to a song called ‘I love myself, I
love my body’. During the final sessions, children
were introduced to the script and began to rehearse
for the play performance. The theater program sessions culminated with an evening play performance
at Illusion Theater in downtown Minneapolis and
a daytime performance at school.
Booster sessions
Children participated in eight weekly after-school
booster sessions. These sessions included activities
such as creating advertisements for fruits and vegetables, having the children paint positive affirmations (e.g. I am special) on a mirror to take home,
and brainstorming ways to be active while watching
television such as doing jumping jacks during commercials. Participants also furthered their physical
activity skills by teaching dance and strength training exercises to their classmates and by learning
exercises to do at home with their families. In addition, booster sessions included rehearsals for the
school performance of the Ready. Set. ACTION!
play and for songs and selected play scenes to be
performed at the final family get-together.
Family component
The family component aimed to enhance home support for behavioral changes through positive
409
D. Neumark-Sztainer et al.
Table I. Baseline characteristics of children, separated by those who responded to follow-up and those who did not respond
P valuea
Child
Baseline total population
n
Mean (SD)
nr
Mean (SD)
t-test
Age
BMI
108
108
10.3 (1.1)
20.9 (5.1)
96
96
10.3 (1.1)
21.1 (5.2)
0.952
0.186
n
%
nr
%
58
14
8
3
25
54
13
7
3
23
53
14
7
1
21
55
15
7
1
22
25
19
64
23
18
59
24
17
55
25
18
57
56
52
52
48
51
45
53
47
37
36
51
49
30
31
49
51
Race
African-American
Asian/Hmong
Whiteb
Hispanicb
Other/mixed
Weight status
BMI > 95th percentile
BMI 85th–95th percentile
BMI < 85th percentile
Condition (children)
Intervention
Control
Condition (parent/guardian)
Intervention
Control
Respondents at follow-up
df
4
Chi square
0.960
2
0.902
1
0.803
1
0.814
SD, standard deviation; BMI, body mass index.
t-tests were used to test for non-response bias in age and body mass index. Chi-square tests were used for the other outcomes, with
baseline percents among all taken as the expected distribution.
b
Indicates pooling of categories, so expected number > 5.
a
reinforcement of healthy behaviors, parent–child
participation in physical activities and availability
of healthy foods. Weekly Fun and Fitness packs
were sent home that included a healthy food with
a simple recipe or fitness incentives for the family
(e.g. pedometers; two of each incentive were sent to
families). A CD of the Ready. Set. ACTION! songs
was also sent home to foster dance at home. Each
pack also had a parent postcard with information
and interactive activities on a topic addressed in
the after-school program (parent postcards are available at http://www.obesityprevention.umn.edu/obp/
Parents/readysetaction.html). There were also two
family events. The first was the performance of the
play by the students at Illusion Theater. The second
family event was held at the school following the
booster sessions. This event was a ‘Ready. Set.
ACTION! DVD Release Party’, which involved
a family viewing of the DVD recording of the play
production, a short performance by the children and
410
a communal family dinner. Each family received
a copy of the DVD.
Process evaluation
Process evaluation included an assessment of program participation, satisfaction and perceived impact among children and parents in the intervention
condition. Sign-in sheets for parents at the play
performance, attendance records for children at
the after-school program and survey questions on
child and parent reported use of take-home items
(e.g. pedometers) were used to assess program participation. Program satisfaction and perceived impact were assessed with child and parent process
surveys. The child survey included 17 close-ended
items (e.g. ‘Overall, how happy were you with the
Ready. Set. ACTION! program?’ with the
responses ‘very happy’, ‘happy’, ‘unhappy’ and
‘very unhappy’) and four open-ended questions
Theater-based obesity prevention
Fig. 1. Intervention components, key behavioral messages, behavioral, personal and environmental constructs addressed within
intervention and evaluation and main outcomes: Ready. Set. ACTION!
(e.g. ‘What are the main things you learned in
Ready. Set. ACTION!?’). The parent survey included 17 close-ended items (e.g. Overall, how satisfied are you with the Ready. Set. ACTION!
program? with the responses ‘very satisfied’, ‘satisfied’, ‘unsatisfied’ and ‘very unsatisfied’) and six
open-ended items. Children completed process sur-
veys at the end of the booster sessions and parents
completed surveys at the final family event. Since
not all parents attended this event, surveys were
also sent home with the post-intervention impact
surveys. Process surveys were completed by 51
children and 39 parents. Additionally, following
the play performances done for the student body,
411
D. Neumark-Sztainer et al.
children who viewed the play completed a brief
survey where they were asked what they learned
from the play and how they could implement these
lessons into their daily life.
Impact evaluation
Children and parents in the intervention and control
groups completed impact surveys at baseline and
following the booster sessions. Constructs included
in the child and parent impact surveys were guided
by SCT [17, 18] and intervention aims (Table II
[19–30]). For variables on the family/home environment, similar questions were asked of both children and parents. Efforts were made to identify
suitable questions/tools that have been used in previous studies and have been pre-tested for comprehension, reliability and/or validity, and were
adapted as needed [14,19–33]. The child survey
was piloted with a convenience sample of nine
fourth to sixth grade students to assess readability,
comprehension, and time required to complete the
survey. The parent survey was tested with four
adults over the phone, to test the feasibility of following up with parents who did not respond to the
mailed version with phone interviews.
Trained research staff administered the child impact surveys at after-school sessions, assessed
height and weight in a private area in the school
using standardized equipment and procedures [19],
and carried out individual interviews with the children to assess dietary intake via a 24-hour dietary
recall and physical activity using the Past Day
Physical Activity Recall [21]. Data collection with
parents (or other caregivers) was done via mailed
surveys and telephone interviews. Surveys were
first sent home to parents for them to complete
and return using a postage paid envelope. Research
staff then called any parents who did not return their
survey by mail to provide them with the opportunity to complete the survey over the phone.
Data analysis
This feasibility study involves two control schools
and two intervention schools and is not powered for
formal statistical testing of program impact [34]. In
412
reporting the results of this pilot study, we focus on
presenting estimates of program implementation,
satisfaction with the program, and program impact
on a variety of health-related behaviors and other
outcomes for both children and parents.
Data analysis to determine if the program is feasible to implement and acceptable to children and
parents is largely descriptive. For close-ended questions on process surveys that children and parents
completed, frequencies and percentages were calculated. For open-ended questions, all responses
were compiled into one document and reviewed
by research team members and theater artists/educators for major themes using principles of content
analysis [35]. Frequencies and percentages were
also calculated for items on the survey completed
by students who viewed the play performance.
For examining program impact, we acknowledge
our inability to conduct a formal statistical analysis
given the low power of this study and instead report
estimates of impact with standard errors reflecting
only individual variability. Outcome analysis uses
baseline-adjusted analysis of covariance for the intervention effect, with covariate adjustment for
child age, gender and for race (black/white/other).
Overall impact is summarized through the number
of outcomes for which our estimates are in the hypothesized direction.
Results
Process evaluation results
Program satisfaction
Satisfaction with the program was reported by 75%
of the children and 90% of the parents in the intervention condition. The vast majority (86% of
children and 92% of parents) said they would recommend the program to others (Table III). In response to an open-ended question on why they
would recommend Ready. Set. ACTION!, parents
commented on both how much their children had
enjoyed the program and how much they felt that
the program had influenced their children’s eating
and activity attitudes and behaviors. For example,
one parent noted, ‘My daughter is learning new
Theater-based obesity prevention
Table II. Impact evaluation measures in the Ready. Set. ACTION! intervention
Measures
Child physical outcomes
BMI (kg/m2)
BMI (Z-score)
Child behaviors
Child dietary intake
Total energy intake (kcal per day)
Fruits and vegetables
(servings per day)
Sweetened beverages
(servings per day)
Child physical activity
(hours day 1 after school)
Television viewing (hours per day)
Response to satiety cues
Child personal factors
Self-efficacy for healthy eating
Self-efficacy for physical activity
Enjoyment of fruits and vegetables
Enjoyment of physical activity
Description of intervention measures
Height and weight measures were taken by trained research staff using standardized
equipment and procedures [19]. Each child was assessed individually in a private
area in the school near where administration of the survey occurred. BMI was
transformed to gender/age-specific Z-scores using the Centers for Disease Control;
Growth Charts method [20].
Dietary intake was assessed using a 1-day 24-hour recall; children were
individually interviewed at school by trained research staff. Dietary intake data
were collected and analyzed using Nutrition Data System for Research software
version 5.0 (2006) developed by the Nutrition Coordinating Center, University
of Minnesota, Minneapolis, MN, USA.
Physical activity was assessed with the Past Day Physical Activity
Recall [21]. Trained staff completed this tool with participants
in a one-on-one interview. Children reported activities completed
within the majority of 30-min blocks of time, starting after school
until 12.00 midnight. Metabolic equivalent (MET) values were coded as light
(<3 METS), moderate (3–6 METS) and vigorous (>6 METS).
On one average weekday, how many hours do you spend watching TV/videos/DVDs;
On an average Saturday or Sunday, how many hours do you spend watching
TV/videos/DVDs [22]; two items, seven response options ranging from 0 to 6+ hours.
I eat everything that is on my plate, even if I’m not that hungry; Even if I’m not that
hungry, I eat all the food that is served to me; When I eat snack foods like chips or
cookies, I eat so much that I feel stuffed; I eat so much at meals that I feel stuffed;
When I eat at a restaurant, I eat so much that I feel stuffed; five items, four response
options with summed range of 5 (hardly ever) to 20 (almost always); items reverse
scored to reflect high level of responsiveness to satiety cues; Cronbach’s alpha = 0.65.
How sure are you that you could: Eat fruit for a snack when you are hungry; Eat
fruit for dessert, even if there are cookies around; Eat vegetables at dinner, even if
they are not your favorite kind; Eat fruit for a snack when you come home from
school; Eat cut-up vegetables for a snack; Choose water instead of soda pop when
I’m thirsty [23]; six items, four response options with summed range of 6 (not at
all sure) to 24 (very sure); Cronbach’s alpha = 0.79.
I can be physically active during my free time on most days; I can be physically
active no matter how busy my day is; I can be physically active no matter how tired
I may feel; I can be physically active, even if I have to stay home; I can be physically
active, even if I could watch TV or play video games instead. Adapted from Ryan
and Dzewaltowski [24]; five items, four response options with summed range of 5
(disagree a lot) to 20 (agree a lot); Cronbach’s alpha = 0.71.
I like the taste of most fruits; I like the taste of most vegetables; I like to have fruit for
a snack; I like to have fruit for dessert; I like to have vegetables and dip for a snack; I
like the taste of most healthy foods. Adapted from Neumark-Sztainer et al. [25]; six
items, four response options with summed range of 6 (disagree a lot) to 24
(agree a lot); Cronbach’s alpha = 0.78.
I enjoy being physically active; Physical activity is fun; I like to do some physical
activity on most days. Adapted from Neumark-Sztainer et al. [25]; three items, four
response options with summed range of 3 (disagree a lot) to 12 (agree a lot);
Cronbach’s alpha = 0.76.
413
D. Neumark-Sztainer et al.
Table II. Continued
Measures
Weight concerns
Body satisfaction
Self-worth
Home environment
Home fruit and vegetable
availability/accessibility
Family support for physical activity
and limiting/reducing TV
Parent weight talk
Description of intervention measures
In the past month, how often have you: Thought about having fat on your body; Felt
fat; Worried about gaining 2 pounds; Thought about wanting to be thinner. Adapted
from Shisslak et al. [26]; four items, four response options with summed range of 4
(never) to 16 (almost always); Cronbach’s alpha = 0.80.
My weight makes me unhappy; I like what I see when I look in the mirror; I think
I have a good body; I’m proud of my body; Most people have a nicer body than me.
Adapted from Mendelson and White [27]; five items, two response options with
summed range of 5 (yes) to 10 (no); selected items reverse scored so that 10 = highest
level of body satisfaction; Cronbach’s alpha = 0.74.
Some kids like the way they are leading their life; Some kids are happy with
themselves as a person; Some kids wish they were different; Some kids are not
very happy with the way they do a lot of things; Some kids are often unhappy with
themselves. Adapted from Harter [28]; five items, three response options with summed
range of 5 (really true for me) to 15 (not true for me); selected items reverse scored so
that 15 = highest level of self-worth; Cronbach’s alpha = 0.46.
Questions about the home environment questions were asked on both parent and child
surveys. Text contained within child survey provided below; parent survey questions
were worded slightly differently.
We have fruits and vegetables in my home; In my home, vegetables are served at
meals; In my home, fruit is served for dessert; In my home, there is fruit available to
have as a snack; In my home, there are vegetables available to have as a snack; In my
home, there are cut-up vegetables in the fridge for me to eat; In my home, there is
fresh fruit on the counter, table or somewhere else where I can easily get them.
Adapted from Rochon et al. [29]; seven items, four response options with summed
range of 7 (hardly ever) to 28 (almost always); Cronbach’s alpha = 0.84 (children);
0.83 (parents).
During a typical week how often has a member of your household: Encouraged you to
do physical activities or play sports; Done a physical activity or played sports with you;
Provided transportation to a place where you can do physical activities or sports;
Watched you participate in physical activities or sports; Limited the amount of time
you can watch TV; Told you that you are doing well in physical activities or sports;
Encouraged you to watch less TV. Adapted from Prochaska et al. [30]; seven items,
four response options with summed range of 7 (not at all) to 28 (everyday);
Cronbach’s alpha = 0.75 (children); 0.80 (parents).
In the past month, how often have your parents/guardians: Made a comment to you
about your weight that made you feel bad; Encouraged you to diet or lose weight;
Made comments about other people’s weight; Gone on a diet; Talked about wanting to
lose weight; Complained about their weight; Complained about how they look; seven
items, four response options with summed range of 7 (never) to 28 (at least once a
week); Cronbach’s alpha = 0.82 (children); 0.85 (parents).
BMI, body mass index.
activities everyday. She can express herself through
acting and dance. She wants to be healthy by eating
better and exercising.’
In response to an open-ended question to the
children about what they liked best about Ready.
Set. ACTION!, many of the children mentioned the
414
dancing, the play performance and the respect they
received within the program. For example, one
child wrote, ‘That we make up dances and we get
to perform and make new friends’. Another child
wrote, ‘That they helped us understand being active
and respecting you are very important’. A third
Theater-based obesity prevention
Table III. Process evaluation results among children and parents in intervention schools who completed process evaluation surveys
at follow-up
Satisfaction with program
Very happy or happy with program
Very satisfied or satisfied with program
Would recommend program to others
Reported use of fitness items sent home
Pedometer (used at least once a week)
Skipping rope (used at least once a week)
Water bottle (used at least once a week)
Exercise band (used at least once a week)
Ready. Set. ACTION! dance music CD (used at least once a week)
Perceived program impact on children
Did the Ready. Set. ACTION! program help you .a
Feel better about yourself? (yes, a lot)
Eat more fruits and vegetables? (yes, a lot)
Reduce the amount of soda pop you drink? (yes, a lot)
Increase the amount of water you drink? (yes, a lot)
Increase the amount of physical activity you do? (yes, a lot)
Reduce the amount of TV/videos you watch? (yes, a lot)
How much did you learn from Ready. Set. ACTION!? (a lot)
Perceived program impact on parents
Based on the messages you learned through the program do you intend to .b
Buy more fruit and vegetables? (yes)
Reduce the amount of soda pop I buy for my family? (yes)
Encourage my family to drink more water? (yes)
Be more physically active with my child? (yes)
Take my child to places where he/she can be physically active? (yes)
Reduce the amount of time my family spends watching TV? (yes)
Make fewer comments about weight or body shape in front of or to my child? (yes)
Children (N = 51)
Parents (N = 39)
n
%
n
%
38
—
44
74.5
—
86.3
—
35
36
—
89.7
92.3
34
29
35
27
27
66.7
56.5
68.6
52.9
52.9
17
16
22
14
—
43.6
41.0
56.4
35.9
—
30
29
27
30
30
26
29
58.8
56.9
52.9
58.8
58.8
50.9
56.9
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
35
28
38
34
36
31
31
89.7
71.8
97.4
87.2
92.3
79.5
79.5
a
Response categories for children: (i) yes, a lot; (ii) yes, somewhat; (iii) yes, a little and (iv) no, not at all.
Response categories for parents: (i) yes and (ii) no.
b
child wrote that the best part was that ‘no one made
fun of me’.
Program participation
More than half of the children (59%, n = 33) had
consistent attendance and participated in at least
75% of the initial theater sessions. Only a third of
the children attended at least 75% of the booster sessions following the play performance (39%, n = 22).
Reasons for not attending more consistently and program attrition over time included moving to a different school, suspension from school, involvement in
other after-school activities, and homework conflicts.
As part of the family outreach, children performed a play at Illusion Theater for an audience
of ;200 people. Many of the children had multiple
family members attend including parents, grandparents, aunts, uncles, and siblings. Out of the 45 children who performed in the play, 23 (51%) had at
least one parent or guardian present. A few additional parents who could not attend the performance
came to see the school-wide performance and some
also attended the final family get-together where
they saw segments of the play.
Another component of family outreach included
family take-home packs. Both children and parents
415
D. Neumark-Sztainer et al.
were asked about whether they used the items that
were sent home. The most popular items were the
water bottles (reported to be used at least weekly by
67% of the children and 56% of the parents) and the
pedometers (used at least weekly by 67% of the
children and 44% of the parents).
Children also had an opportunity for peer outreach.
Approximately 900 first to sixth grade students
viewed the school-wide performances of the play.
The fourth through sixth grade students who
viewed the play (n = 366) completed a brief viewer
survey.
Perceived program impact
Children who participated in the theater program
were asked a series of questions on whether they
thought the program helped them feel better
about themselves and make changes in their eating
and physical activity behaviors (Table III). Approximately half of the children reported that they
felt that the program had helped them ‘a lot’ in
making these changes and that they had learned
a lot from Ready. Set. ACTION!. Responses to an
open-ended question about the main things they
learned further indicated that they understood the
main messages; for example (in their own spelling):‘to not watch that much TV and to eat a lot
of vegitble, water and fruit’ and ‘to fell very good
about ur selfs’.
The majority of parents reported their intentions
to make changes in the home environment with
regard to food, physical activity and weight talk
(i.e. making fewer comments about weight or body
shape) (Table III). Intentions were higher for positive changes such as encouraging family members
to drink more water (97%) than for restrictive
behaviors such as reducing the amount of soda
pop purchased (72%).
Finally, among the 366 children who viewed the
school play, 29% reported learning a lot from the
play and an additional 59% reported learning ‘quite
a bit’ or ‘some’ from watching the play. Many children indicated that after watching the play, they
planned on making behavioral changes such as eating more fruits and vegetables (73%), although
416
numbers were lower for restrictive behaviors such
as watching less TV (48%).
Impact evaluation results
Details of baseline-adjusted follow-up results among
intervention and control conditions are presented in
Table IV. Overall, 13 of 21 outcomes were in the
hypothesized direction. Only self-efficacy to be
physically active showed a statistically significant
difference in the desired direction. Based upon child
reports, weight talk (e.g. parent comments about
weight and parent dieting) at home was higher
among intervention families than among control
families; this change was not in the desired direction.
Discussion
The primary aim of this study was to develop and
test the feasibility of a theater-based obesity prevention program for ethnically diverse and low-income elementary school children and their parents.
We were interested in determining the feasibility
and potential utility of implementing a theaterbased intervention with outreach to children’s families. High percentages of children and parents in
the intervention condition reported that they
enjoyed the program and that they had made
changes or intended to make positive changes in
their behaviors as a result of program participation.
However, the impact evaluation found few meaningful differences between the intervention and
control conditions. In interpreting the findings from
the impact evaluation, it is important to note that the
study was designed as a feasibility study; we did not
anticipate that the theater intervention, on its own,
would lead to meaningful behavioral changes, nor
power the study to detect changes. The combined
process and impact evaluation results suggest that
the intervention was effective in leading to increased awareness of the need for behavioral
change, but was not powerful enough on its own
to lead to behavioral change. We concluded that
a theater-based school program offers promise as
a strategy for reaching diverse and hard-to-reach
children and parents with messages of relevance
Theater-based obesity prevention
Table IV. Impact evaluation baseline-adjusted follow-up results among children and parents (where applicable) in intervention and
control conditions (adjusted for child age, gender and race)a
Child physical outcomes
BMI (kg/m2)
BMI (Z-score)
Child behaviorsa
Total energy (kcal per day)
Fruit and vegetables (servings per day)
Sweetened beverages (servings per day)
Responds to satiety cues
Physical activity (total) (hours per day)
Television viewing (hours per day)
Child personal factors
Self-efficacy: healthy eating (range: 6–24)
Self-efficacy: physical activity (range: 6–24)
Enjoy fruits/vegetables (range: 6–24)
Enjoy physical activity (range: 3–12)
Weight concerns (range: 4–16)
Body satisfaction (range: 5–10)
Self-worth (range: 5–15)
Family and home environment
Home fruit/vegetable availability (range: 7–28), child report
Home fruit/vegetable availability (range: 7–28), parent report
Family support: physical activity (range: 7–28), child report
Family support: physical activity (range: 7–28), parent report
Parent weight talk (range: 7–28), child report
Parent weight talk (range: 7–28), parent report
Intervention
Control
Mean (SE)
Mean (SE)
P value
Desired
direction?
21.5 (0.25)
0.81 (0.05)
21.7 (0.26)
0.89 (0.05)
0.598
0.284
Yes
Yes
1543 (92)
3.21 (0.35)
0.61 (0.19)
14.4 (0.54)
2.62 (0.34)
2.28 (0.20)
1723 (93)
3.60 (0.35)
0.84 (0.19)
14.0 (0.58)
2.38 (0.35)
2.34 (0.22)
0.190
0.454
0.430
0.608
0.651
0.857
Yes
No
Yes
Yes
Yes
Yes
17.0 (0.59)
15.7 (0.48)
19.0 (0.59)
10.1 (0.27)
8.34 (0.41)
8.16 (0.20)
10.80 (0.30)
17.2 (0.64)
14.1 (0.52)
18.6 (0.64)
10.3 (0.29)
7.88 (0.44)
8.08 (0.22)
11.48 (0.33)
0.811
0.028
0.669
0.715
0.462
0.810
0.143
No
Yes
Yes
No
No
Yes
No
20.2 (0.65)
21.5 (0.77)
18.1 (0.55)
17.4 (0.64)
13.9 (0.73)
12.7 (0.83)
20.6 (0.70)
21.2 (0.77)
17.3 (0.59)
16.8 (0.64)
11.3 (0.78)
11.0 (0.82)
0.735
0.758
0.316
0.560
0.022
0.147
No
Yes
Yes
Yes
No
No
SE, standard error; BMI, body mass index.
Analyses were done on 51 intervention and 45 control children. Analyses for parent report of home environment were done on 30
intervention and 31 control parents.
a
to health promotion. However, given the complexity
of behavioral change, in order to actually lead to
meaningful behavioral changes that are likely to impact weight status, school-based theater-based programs need to be incorporated into more
comprehensive obesity prevention efforts that reach
out to children, families and communities and have
both educational and environmental components.
A strength of Ready. Set. ACTION! was its innovative use of theater. The artists/educators translated the key messages into words and songs that
were understandable and fit the children’s lived
experiences, so the program content was personally
and culturally relevant to the children and their
parents. However, to ease the workload and im-
prove the quality of the final play, our recommendation for the future would be to build from an
existing script with a plan to tailor it with the student
performers. Additionally, although after-school programs offer an excellent venue for reaching children
without interfering with their academic studies,
child attendance at the after-school program was
not consistent, children sometimes arrived with less
than full concentration, and the structure tended to
be looser than during the school day. Thus, we
would recommend trying to implement the intervention as part of the regular school day.
The high levels of program satisfaction among
participating parents and their stated intentions toward making behavioral change are a testament to
417
D. Neumark-Sztainer et al.
the value of engaging children in a theater performance as a way to inform parents about health promotion activities in which their children are
participating. However, as previously reported [7,
36], it can be difficult to get parents, particularly
low-income parents, to attend educational activities. While many of the children had multiple family members present at the evening theater play
performance, nearly half of the children’s parents
did not attend. The preparation and distribution of
the Ready. Set. ACTION! DVD, which documented different aspects of the intervention and included parts of the children’s play performance,
provided a way to reach out to parents who could
not attend the performance and to reinforce messages among all children and parents.
There were additional benefits of a theater-based
program such as Ready. Set. ACTION! that are not
related to the goal of obesity prevention, but are
worthy of mention. These benefits relate to the
introduction of the arts to a population that may
only have had minimal exposure to theater. For
example, one girl displayed strong dancing skills
and was offered a scholarship to a local dancing
studio to further her studies. Additionally, for the
first time, one of the intervention schools embarked
on producing a musical and a boy who participated
in Ready. Set. ACTION! (but previously had no
acting experience) had the lead role. Furthermore,
program leaders perceived that the theater experience had a positive impact on different aspects
of the children’s well-being (e.g. confidence and
communication).
It is noteworthy, and somewhat disconcerting,
that Ready. Set. ACTION! led to an increase in
child reports of parental weight talk (e.g. parental
comments about their own weight or child’s
weight). The program messages were designed to
reduce the emphasis on weight and focus on making changes in the home environments to facilitate
healthful eating and physical activity behaviors.
While it may have been that families engaged in
more weight-related discussions following program
participation, an alternative explanation for this
finding is that the intervention children were more
sensitized to weight-related discussions at home.
418
This latter explanation is somewhat supported by
the finding that in the process evaluation, 80% of
intervention parents reported that they intended to
‘make fewer comments about weight or body
shape’ based on the messages learned in the program. Of further note, we do not know the content
or tone of the discussions that occurred (e.g.
whether it was done in a helpful or non-critical
manner). However, since results from previous
studies have shown that talking about weight at
home can be detrimental to healthy weight management [37, 38], future interventions should be more
explicit in emphasizing that weight talk at home is
not helpful and may be harmful. Strategies for decreasing weight talk at home should be clearly
addressed via the inclusion of specific messages
about weight talk in the theater production and
take-home newsletters to parents. The negative consequences of talking about dieting and weight
should be discussed and alternative strategies for
focusing on healthy eating and physical activity
should be provided to parents.
Although difficult, it is crucial to develop, implement and evaluate interventions that have the potential to (i) reach hard-to-reach populations at
greatest risk for health problems such as obesity
and (ii) change hard-to-change behaviors of relevance to obesity. A theater-based program such as
Ready. Set. ACTION! provides an innovative strategy for reaching children and families from diverse
backgrounds with culturally appropriate messages.
Findings from the current study indicate that such
an approach is feasible to implement within school
settings with the help of community theater groups.
However, in order to be effective in behavioral
change among children and parents, the program
should be incorporated into a more comprehensive
family, school and community obesity prevention
effort that includes educational and environmental
components.
Funding
National Institutes of Health (R21 DK072972
to D.N.S.); National Institute of Diabetes and
Theater-based obesity prevention
Digestive and Kidney Diseases; The Illusion Theater received additional funding for the theater components from The Medica Foundation, The General
Mills Communities of Color Project Grants and The
Best Buy Children’s Foundation.
Conflict of interest statement
None declared.
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Received on February 4, 2008; accepted on June 3, 2008